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Objectives The efficacy of and indications for cytological reexamination to detect malignant changes in branch duct type intraductal papillary mucinous neoplasms (BD-IPMNs) have not been studied in detail. We conducted a retrospective study to evaluate the efficacy and indications of cytological reexamination by using pancreatic juice (repeated cytology) for BD-IPMNs. Methods Forty-five patients who underwent repeated cytology after a diagnosis of benignancy by using initial cytology were recruited for this study. Results Thirty-eight patients, excluding 7 patients with lack of surveillance period after the final cytology, were classified into Malignancy (n = 13) and Benignancy groups (n = 25) on the bases of the findings from resected specimens or changes in BD-IPMNs after repeated cytology. The sensitivity and specificity to detect malignant changes in BD-IPMNs by using repeated cytology were 62% and 100%, respectively. For the 12 patients with mural nodules (MNs) ≥ 5 mm (67% of them were malignant), the sensitivity was 50%, whereas, for the 26 patients without MNs ≥ 5 mm (19% of them were malignant), it was 80%. In addition, malignant changes in BD-IPMNs after initial cytology occurred in 62% of the patients with changes in the MNs and 27% of the patients with an increase in the cyst size. Conclusion Repeated cytology can play a role in the determination for surgery even after a diagnosis of benignancy by using initial cytology, especially for BD-IPMNs without MNs ≥5 mm. In addition, changes in the MNs or cyst size may be appropriate indications for repeated cytology.

Objectives For benign pancreatic duct strictures/obstructions (BPDS/O), endoscopic ultrasonography-guided pancreatic drainage (EUS-PD) is performed when endoscopic transpapillary pancreatic drainage (ETPD) fails. We clarified the clinical outcomes for patients with BPDS/O who underwent endoscopic interventions through the era where EUS-PD was available. Methods Forty-five patients with BPDS/O who underwent ETPD/EUS-PD were included. We retrospectively investigated overall technical and clinical success rates for endoscopic interventions, adverse events, and clinical outcomes after successful endoscopic interventions. Results The technical success rates for ETPD and EUS-PD were 77% (35/45) and 80% (8/10), respectively, and the overall technical success rate using two drainage procedures was 91% (41/45). Among the 41 patients who underwent successful endoscopic procedures, the clinical success rates were 97% for the symptomatic patients (35/36). The rates of procedure-related pancreatitis after ETPD and EUS-PD were 13% and 30%, respectively. After successful endoscopic interventions, the cumulative 3-year rate of developing recurrent symptoms/pancreatitis was calculated to be 27%, and only two patients finally needed surgery. Continuous smoking after endoscopic interventions was shown to be a risk factor for developing recurrent symptoms/pancreatitis. Conclusions By adding EUS-PD to ETPD, the technical success rate for endoscopic interventions for BPDS/O was more than 90%, and the clinical success rate was nearly 100%. Due to the low rate of surgery after endoscopic interventions, including EUS-PD, for patients with BPDS/O, EUS-PD may contribute to their good clinical courses as a salvage treatment for refractory BPDS/O.

Background and study aims A newly developed peroral cholangioscopy (POCS) system, SpyGlassDS has high maneuverability. This study aimed to evaluate acceptability of the accuracy of SpyGlassDS accompanied by simultaneous POCS-guided biopsy compared with that of a traditional POCS scope, CHF-B260, to diagnose the lateral extent of extrahepatic cholangiocarcinoma (LEC). Patients and methods Patients who underwent surgical resection after preoperative examinations to diagnose LEC were evaluated. POCS by CHF-B260 was performed if there was discrepancy between preceding fluoroscopy-guided biopsy findings and other examinations between January 2004 and September 2015 (group A, n = 56); and POCS plus POCS-guided mapping biopsy by SpyGlassDS was performed in all surgical candidates between October 2015 and December 2017 (group B, n = 20). The main outcome measure was the accuracy of overall preoperative diagnosis (OPD) of LEC defined based on all examinations, including POCS. Results Accuracy of OPD for the liver side and the ampullary side was 93 % and 100 %, respectively, in group A, and 84 % and 100 %, respectively, in group B (P = 0.37 for the liver side; P, not available for the ampullary side). Diagnostic accuracy of simple optical evaluation by POCS for the liver side and the ampullary side was 83 % and 100 %, respectively, in group A, and 58 % and 88 %, respectively, in group B (P = 0.29 for the liver side; P = 0.40 for the ampullary side). Conclusions POCS by SpyGlassDS was found to be acceptable and could be a standard approach for diagnosis of LEC.

The Japan Gastroenterological Endoscopy Society has developed the 'EPLBD Clinical Practice Guidelines' as fundamental guidelines based on new scientific techniques. EPLBD is a treatment method that has recently become widely used for choledocolithiasis. The evidence level in this field is usually low, and in many instances, the recommendation grading has to be determined on the basis of expert consensus. At this point, the guidelines are divided into the following six sections according to the 'EST Clinical Practice Guidelines': (i) Indications, (ii) procedures, (iii) special cases, (iv) procedure-related adverse events, (v) treatment outcomes, and (vi) postoperative follow up observation.

The Japan Gastroenterological Endoscopy Society (JGES) has recently compiled guidelines for endoscopic sphincterotomy (EST) using evidence-based methods. Content regarding actual clinical practice, including detailed endoscopic procedures, instruments, device types and usage, has already been published by the JGES postgraduate education committee in May 2015 and, thus, in these guidelines we avoided duplicating such content as much as possible. The guidelines do not address pancreatic sphincterotomy, endoscopic papillary balloon dilation (EPBD), and endoscopic papillary large balloon dilation (EPLBD). The guidelines for EPLBD are planned to be developed separately. The evidence level in this field is often low and, in many instances, strong recommendation has to be determined on the basis of expert consensus. At this point in time, the guidelines are divided into six items including indications, techniques, specific cases, adverse events, outcomes, and postoperative follow up.

Objective Patients with perihilar malignancy often develop recurrence of infectious cholangitis, which makes further transpapillary intervention extremely difficult. As endoscopic ultrasound (EUS)-guided biliary drainage (EUS-BD) of an intrahepatic bile duct is a possible option for additional intervention, the aim of this study was to estimate the feasibility of such intervention. Methods and Patients Patients who had undergone EUS-BD after further transpapillary intervention was deemed impossible or ineffective were investigated in this study. Those who had not received previous interventions via the papilla were excluded. Procedure-related adverse events, clinical efficacy, and time to recurrence of jaundice or infectious cholangitis transthyretin (TTR) were evaluated. Results Seven patients were eligible for the study between 2007 and 2016 (7 men; mean age, 77 years; 4 with perihilar cholangiocarcinoma and 3 with intrahepatic cholangiocarcinoma). No procedure-related adverse events were observed. EUS-BD was clinically effective and enabled hospital discharge in 4 patients (57%). The TTR in these 4 clinically effective patients was 43, 105, 118, and 147 days after the procedure (median, 112 days). Conclusion EUS-BD was found to be safe and often effective in patients in whom additional transpapillary intervention had become difficult, although its efficacy was limited to a short period.

We herein report a 68-year-old man with branch duct intraductal papillary mucinous neoplasms of the pancreas (BD-IPMNs) involving type 1 localized autoimmune pancreatitis (AIP) with normal serum IgG4 levels. Although he was referred to our medical center due to suspicion of pancreatic cancer concomitant with BD-IPMNs, endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) revealed a mass suspected of being pancreatic cancer to be type 1 AIP. Steroid administration notably reduced the mass. Although the clinical diagnosis of pancreatic masses in patients with IPMN can be occasionally challenging, performing a pathological examination by EUS-FNA may prevent unnecessary pancreatic surgery in cases of possible AIP.

We herein report a case of intracholecystic papillary-tubular neoplasm (ICPN) of the gallbladder in which jaundice developed. A 58-year-old woman with jaundice was referred to our hospital. Computed tomography revealed a papillary tumor in the body of the gallbladder protruding into the bile duct. A transpapillary biopsy of the bile duct verified adenocarcinoma, and pancreatoduodenectomy with extended cholecystectomy was performed. The tumor spread macroscopically from the gallbladder body to the cystic duct, thus forming a polypoid mass protruding into the bile duct. This is a rare case of invasive carcinoma from ICPN leading to mechanical obstruction of the bile duct.

Background and Aim Although biliary cannulation with pancreatic guidewire placement (P-GW) is useful for difficult cases in endoscopic retrograde cholangiopancreatography (ERCP), the clinical significance of wire-guided cannulation with P-GW (double-guidewire technique: DGT) has not been clarified. The aim of the present study was to evaluate the usefulness of DGT for difficult biliary cannulation after unsuccessful biliary cannulation using a cannula/sphincterotome under guidance of injected contrast with P-GW (single-guidewire technique: SGT). Methods One-hundred and forty-six patients with difficult biliary cannulation who underwent SGT were included in this retrospective study. DGT was carried out if SGT was unsuccessful. Pancreatic duct (PD) stenting was attempted to prevent post-ERCP pancreatitis (PEP) in all patients. The success rate of cannulation and the risk factors for PEP were investigated. Results Biliary cannulation with SGT was achieved in 70%. DGT was carried out in 25 patients with unsuccessful SGT, biliarycannulation being successful in 72%. Of the 13 patients who underwent precut sphincterotomy, biliary cannulation was achieved in 46%. The incidence of PEP in patients who had undergone SGT, DGT, and precut sphincterotomy was 8% (12: mild, 8; moderate, 3; severe, 1), 4% (mild, 1), and 0%, respectively. PD stenting was successfully carried out in 86%. Multivariate analysis revealed unsuccessful PD stenting to be the only risk factor for PEP (OR 8.3, 95% CI 2.3–30). Conclusions DGT may replace SGT or become the salvage procedure in cases of unsuccessful SGT as a result of its high success rate with an acceptable incidence of PEP. Failed pancreatic duct stenting in these techniques was frequently associated with PEP.

Pancreatobiliary reflux (PBR) can occur in individuals without pancreaticobiliary maljunction. The aim of this study was to elucidate the incidence of PBR in individuals with a normal pancreaticobiliary junction and its impact on the biliary tree.Data were prospectively collected from 15 centers on 420 patients with a morphologically normal pancreaticobiliary junction who had undergone bile sampling and measurement of the biliary amylase level. We investigated the incidence and predictive factors for high biliary amylase levels (HBAL), as well as the relationship of HBAL with biliary malignancy.Twenty-three patients (5.5%) showed HBAL (≥10,000 IU/L). Univariate analysis showed that risk factors for the elevation of biliary amylase levels were the existence of a relatively long common channel (≥5 mm), acute pancreatitis, and papillitis. Multivariate analysis revealed that only the existence of a relatively long common channel was a significant factor for PBR. Biliary amylase levels in patients with a relatively long common channel were significantly higher than in patients without a long common channel (12,333 vs. 2,070 IU/L, P = 0.001). The incidence of HBAL (P0.001), as well as the overall biliary amylase levels (P = 0.007) were significantly higher in patients with gallbladder cancer than in those without gallbladder cancer.The PBR was frequently observed in individuals with a relatively long common channel. Patients showing HBAL with normal pancreaticobiliary junction are at high risk for gallbladder cancer.

A metal stent has a longer stent patency than a plastic stent in patients with unresectable malignant distal biliary stricture. However, treatment for stent dysfunction of a metal stent remains unresolved. A review of reported articles regarding reintervention for metal stent dysfunction showed that causes of stent dysfunction included tumor ingrowth/overgrowth, stone/sludge/food impaction, and stent migration. Cleaning of the stent is associated with an early relapse of stent dysfunction. Additional placement of a covered metal stent is expected to have a longer stent patency than that of other stents such as uncovered metal stents or plastic stents. It is recommended that occluded covered metal stents be removed if possible. Stent trimming with argon plasma coagulation is sometimes useful for the treatment of stent displacement. No strategy for occluded metal stents has been established yet. Further clinical trials regarding proper treatments are necessary.

Objective To retrospectively evaluate the risk factors for post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) and stent dysfunction after performing preoperative biliary drainage (BD) in patients with malignant biliary stricture. Methods Between January 2003 and February 2013, 105 consecutive patients who had undergone transpapillary BD before surgery were enrolled in this study. Procedure-related complications, stent dysfunction rates, and their respective risk factors were investigated. PEP was defined according to the consensus guidelines. Results Fifty-five patients had bile duct cancer, 31 had pancreatic cancer, 16 had ampullary cancer, and 3 had gallbladder cancer. Endoscopic biliary stenting (EBS) and nasobiliary drainage (NBD) were performed in 84 patients and 21 patients, respectively. PEP occurred in 10% of the patients, with a significantly higher frequency in those with hilar/upper bile duct stricture (p=0.026) and a normal bilirubin level at admission (p=0.016). Of the 84 patients who underwent initial EBS, stent dysfunction occurred in 13%. The mean number of days from EBS to stent dysfunction was 14±12 days. A multivariate analysis revealed a male gender (p=0.048), a stent diameter ≤8 Fr (p=0.036), and an ERCP procedure time ≥45 minutes (p=0.021) to be risk factors for stent dysfunction. No NBD tube dysfunction was observed. Conclusion Patients with upper/hilar bile duct stricture or a normal bilirubin level are at high risk of developing PEP after preoperative BD. NBD or EBS with a large-bore stent is therefore recommended as preoperative BD.

Background and Aims The aim of this study was to elucidate the efficacy of pancreatic juice cytology with the cell-block method (CB-PJC) for the determination of surgery in patients with branch duct intraductal papillary mucinous neoplasm (BD-IPMN). Methods In 138 patients with BD-IPMN from whom pancreatic juice was collected under ERCP for CB-PJC, we retrospectively evaluated the following: (1) the rate of successfully evaluated CB-PJC; (2) the ability of CB-PJC to diagnose malignancy and to identify pathologic subtypes in resected BD-IPMNs; (3) the rate of development into invasive cancer and progression of BD-IPMNs in patients with BD-IPMNs diagnosed as benignancy by CB-PJC; and (4) post-ERCP adverse events. Results (1) The success rate of CB-PJC was 89.9%. (2) The sensitivity and specificity of CB-PJC for preoperative diagnosis of malignancy were 50% and 100%, respectively, with only hematoxylin and eosin staining, whereas they were 79% and 100%, respectively, by adding immunohistologic staining. The agreement rate of the preoperative subtypes by CB-PJC with the subtypes of resected specimens was 93%. (3) The onset of invasive cancer was not detected at all on imaging studies, whereas the progression of IPMN was detected in 14 patients. Multivariate analysis revealed the risk factor of progression to be non-gastric type. The cumulative 5-year progression rate in this group was 89%. (4) Post-ERCP pancreatitis developed in 13 patients (7.7%). Conclusions The diagnostic efficacy of preoperative CB-PJC for malignant BD-IPMN was excellent. The results may suggest the feasibility of applying preoperative subtyping by CB-PJC for decisions as to whether surgery is indicated.

Recently, the clinical application of diffusion-weighted magnetic resonance imaging (DWI) has been expanding to abdominal organs. However, only a few studies on gallbladder diseases have been published. The aim of this study was to evaluate the usefulness and limitations of high b-value DWI for gallbladder diseases. A total of 153 patients (mean age 60 ± 15 years, 78 males) who had undergone DWI for evaluating gallbladder wall thickening or polypoid lesions were included in this study. Of these 153 patients, 36 had gallbladder cancer and 117 had benign gallbladder diseases (67 chronic cholecystitis, 44 adenomyomatosis, four cholesterol polyp, one gallbladder adenoma, and one xanthogranulomatous cholecystitis). We evaluated the positive signal rate with DWI and the apparent diffusion coefficient (ADC) value of each disease. The positive signal rate with DWI was significantly higher in gallbladder cancer (78 %) than in benign gallbladder diseases (22 %) (p

Background and Aim: Although reports on endosonography-guided biliary drainage (ESBD) have been increasing, only a few reports on deployment of a self-expandable metal stents (SEMS) have been reported. The aim of the present study was to evaluate the safety and efficacy of SEMS deployment in ESBD. Methods: Of 42 patients who underwent ESBD during the period from January 2007 to August 2011, 21 patients with unresectable malignant biliary obstruction in whom SEMS deployment had been attempted were included. In the first session, a plastic stent or SEMS was placed in a bilio-enteric anastomosis (BEA) method. SEMS was deployed with the one-step technique or with replacement of a plastic stent with a SEMS in the second session. The technical success, early and late complications, and stent patency of SEMS were evaluated. Results: One-step SEMS deployment was attempted in seven patients, and SEMS was deployed with stent exchange in 14. SEMS deployment was successful in all patients without any complications. Finally, SEMS was placed in a BEA method in 16 patients (extrahepatic bile duct, 13; intrahepatic bile duct, three), and with antegrade deployment in five. Late complications occurred in three patients who underwent deployment of SEMS in a BEA method (stent obstruction in two and reflux cholangitis in one). The mean stent patency period was 433 days. Conclusions: As SEMS deployment in ESBD is safe and provides long stent patency, a SEMS seems to be the stent of choice in ESBD for patients with unresectable malignant biliary obstruction in whom long survival is expected.

The causes of benign biliary stricture include chronic pancreatitis, primary/immunoglobulin G4-related sclerosing cholangitis and complications of surgical procedures. Biliary stricture due to fibrosis as a result of inflammation is sometimes encountered in patients with chronic pancreatitis. Frey's procedure, which can provide pancreatic duct drainage with decompression of biliary stricture, can be an initial treatment for chronic pancreatitis with pancreatic and bile duct strictures with upstream dilation. When patients are high-risk surgical candidates or hesitate to undergo surgery, endoscopic treatment appears to be a potential second-line therapy. Placement of multiple plastic stents is currently considered to be the best choice as endoscopic treatment for biliary stricture due to chronic pancreatitis. Temporary placement with a fully covered metal stent has become an attractive option due to the lesser number of endoscopic retrograde cholangiopancreatography (ERCP) sessions and its large diameter. Further clinical trials comparing multiple placement of plastic stents with placement of a covered metal stent for biliary stricture secondary to chronic pancreatitis are awaited.

Purpose: To visualize the movement of pancreatic juice noninvasively by using an unenhanced magnetic resonance (MR) imaging technique. Materials and Methods: Institutional review board approval and informed consent were obtained for this study. A flow-out technique of time-spatial labeling inversion pulse (SLIP) technique was applied using both nonselective and selective inversion pulses to label, or tag, pancreatic juice to move out of the region. Ten normal (eight men, two women; age range, 22–61 years; mean age, 35 years) and two pathologic conditions were examined on a commercially available 1.5 Tesla MR imager with quadrature-detected phased-array coils. All images were evaluated by two radiologists to assess depiction of the pancreatic juice movement or pancreatic juice reflux as compared to the pancreatic duct or the common bile duct on MRCP obtained before time-SLIP examination. Results: The tagged pancreatic juice was satisfactory visualized after applying the pulse labeling. Noninvasive visualization of pancreatic juice movement, including normal pancreatic juice movement and reflux from the main pancreatic duct into the common bile duct, was possible by using the unenhanced time-SLIP technique. Conclusion: Noninvasive visualization of pancreatic juice movement is possible by using the unenhanced MR imaging time-SLIP technique. J. Magn. Reson. Imaging 2012;35:1019-1124. © 2011 Wiley Periodicals, Inc.

Aim: To elucidate the diagnostic efficacy of the cell block (CB) method by comparing it with that of conventional smear cytology for pancreatic juice obtained by endoscopic retrograde cholangiopancreatography (ERCP) in a randomized controlled trial fashion. Methods: A total of 170 patients with pancreatic lesions suspicious of being malignant who underwent pancreatic juice collection without giving secretin under ERCP were enrolled in this study. After sampling, the pancreatic juice was randomized to the CB method (n = 85) or to smear cytology (n = 85). CB sections were subjected to hematoxylin-eosin, periodic acid Schiff–Alcian blue, and immunohistochemical stains. Both Papanicolaou stain and Giemsa stain were used for smear cytology. Results: The final diagnosis was malignancy in 54 patients: pancreatic cancer, 45; intraductal papillary-mucinous carcinoma, six; and endocrine tumor, three. The number of patients with a cytological borderline malignancy in the CB group (3.5%) was significantly smaller than that in the smear group (27.1%) (P

Aim: To evaluate the usefulness of a modified technique of endoscopic papillectomy (EP) for lessening the occurrence of complications. Methods: Indications for EP were adenoma or well-differentiated adenocarcinoma confined to the papilla of Vater (T1) without tumor spread into the bile/pancreatic duct. Sixteen patients underwent the modified technique, which consists of resection with the Endocut® mode, followed by biliary/pancreatic sphincterotomy and stenting (Group A). Twelve patients who had undergone EP, using a cutting current, followed by pancreatic duct stenting were included as control (Group B). The frequency of complications and clinical outcomes were retrospectively compared between the two groups. Results: Sixteen patients had adenoma, and 12 had adenocarcinoma. Early complications occurred in 36% of all patients (hemorrhage, 7; cholangitis, 3; perforation, 2; cholecystitis, 1). The frequency of early complications in Group A was significantly lower than that in Group B (6% vs 75%, odds ratio [OR] 0.022, 95% confidence interval [CI], 0.0020–0.25). Late complications occurred in 18% of the patients (bile duct stone, 3; hemorrhage, 1; pancreatitis, 1). There was no significant difference in the late complication rate between Group A and Group B (19% vs 17%). Local recurrences were found in 14% of the patients, without a significant difference between Group A and Group B (19% vs 8%) during a mean follow-up period. All recurrent tumors were successfully treated with argon plasma coagulation. Conclusions: The modified technique of EP for ampullary neoplasm contributed to lessening the occurrence of early complications. However, further refinement of this technique is necessary for improving the clinical outcome.

Background: Intraductal papillary mucinous neoplasms (IPMN) of the pancreas tend to spread intraepithelially along the pancreatic duct wall. We evaluated histopathological intraductal lateral spread (LS) along the main pancreatic duct (MPD) from branch-duct IPMN and investigated the usefulness of intraductal ultrasonography (IDUS) for its preoperative diagnosis. Patients and Methods: Twenty-four patients with branch-duct IPMN who had undergone preoperative IDUS and surgery were reviewed clinicopathologically. The prevalence and histological length of LS along the MPD from branch-duct IPMN, characteristics of the patients with LS, and efficacy of LS assessment by IDUS were examined. Results: LS along the MPD was observed in 54% of the subjects. In the group of patients with LS, its mean length was 25.2 ± 16.8 mm (5–50 mm) and the diameter of the MPD was 6 mm or greater. Of the patients with LS, those in whom the length of LS along the MPD was longer than the diameter of the cystically dilated branch accounted for 30%. The diameter of the MPD in the group with LS was significantly greater than that in the group without LS (P = 0.03). The sensitivity, specificity, and overall accuracy of IDUS in the detection of LS were 92%, 91%, and 92%, respectively. Conclusion: LS along the MPD was detected in about half of the resected cases of branch-duct IPMN. Preoperative transpapillary IDUS may be beneficial for the determination of the resection line, especially in those branch-duct IPMN patients in whom the MPD is 6 mm or greater in diameter.

Background: The aim of this study was to evaluate the efficacy and safety of endoscopic bilateral biliary metal stent placement for hilar malignant obstruction. Patients and Methods: Twenty patients with unresectable malignant hilar biliary obstruction who had undergone endoscopic bilateral Y-configured biliary drainage with metal stents were enrolled as a study group (YMS group). Thirty-seven patients who had undergone bilateral drainage with plastic stents were selected as a historical control (PS group). Two newly designed metal stents for bilateral Y-configured placement were endoscopically deployed in a partial stent-in-stent manner in one session. Technical success, early complications, and stent patency were evaluated. Results: The technical success rate in the YMS group was 100%. Mild post-endoscopic retrograde cholangiopancreatography pancreatitis occurred in one patient in the YMS group and in two in the PS group. The success rate of biliary decompression was 95% in the YMS group and 89% in the PS group (P = 0.65). During a median follow-up period of 7.3 months, the incidence of stent occlusion in the YMS group was significantly lower than that in the PS group (30% vs 62%, P = 0.028). Mean stent patency in the YMS group was 250 days and that in the PS group was 115 days (P = 0.0061). Risk factors for stent occlusion were bile duct cancer (P = 0.035) and the PS group (P = 0.07) by multivariate analysis. Conclusion: Single-session endoscopic bilateral biliary placement of newly designed metal stents for hilar malignant obstruction is safe and useful with a high technical success rate and a long patency period.

Endosonography-guided biliary drainage (ESBD) is gaining attention as a promising drainage technique for obstructive jaundice. However, histological changes resulting from ESBD have not been well understood. We had an opportunity to histologically investigate the influence of ESBD, established between the left hepatic duct and the stomach, on the relevant organs in an autopsy case with bile duct cancer extending from the pancreatic head to the hepatic hilum with duodenal invasion. Localized fibrous connective tissues were present around and along the sinus tract, including the connection between the surfaces of the left lobe of the liver and the gastric serosa, without hemorrhage, inflammatory changes, or cancer invasion. The inside of the ESBD stent was slightly stenotic at the intramural portion of the stomach due to proliferation of granulation tissue. No bile stasis or abscess was observed in the left lobe. These results are quite suggestive of the high safety and efficacy of ESBD with adequate performance.

This study assessed the mechanism of fistula formation in intraductal papillary mucinous neoplasm (IPMN) of the pancreas.A total of 274 patients with IPMN who had been diagnosed by endoscopic retrograde cholangiopancreatography and endoscopic ultrasonography (EUS) at our center were enrolled. The patients with IPMN which had fistula formation into other organs were investigated retrospectively as to (1) clinical prevalence and the organs penetrated by IPMN, (2) analysis of the mechanism of fistula formation by immunohistopathological study, (3) efficacy of EUS in progression assessment, and (4) prognosis.Among the subjects, fistula formation into other organs was observed in 18 patients (6.6%) and into 28 organs. There were 7 patients (39%) in whom multiple organs were penetrated. Of 16 patients who had undergone investigation of the expression of mucin markers, 94% had an intestinal-type tumor. Of 9 patients who had undergone surgery or autopsy, 67% showed mechanical penetration without invasion around the fistula. Only papillary protrusions were seen by EUS in 4 of these patients with noninvasive papillary adenocarcinoma showing mechanical penetration. All 5 patients who had pancreatic parenchymal invasion showed a mass with a mixed-echo pattern in addition to papillary protrusions shown by EUS, corresponding to colloid carcinoma.There were 2 processes in the development of fistulas in IPMN. Of those patients showing fistula formation, 94% had intestinal-type IPMN, and 67% showed mechanical penetration. Delineation of a mass with the mixed-echo pattern suggested an invasive penetration due to colloid carcinoma.

Transpapillary endoscopic biliary drainage is a well-accepted technique for patients with biliary obstruction. However, transpapillary access to the bile duct is not always possible, especially in patients with duodenal stenosis or difficult cannulation of the bile duct during endoscopic retrograde cholangiopancreatography. Percutaneous transhepatic biliary drainage or surgical bypass has been performed in cases of unsuccessful endoscopic retrograde cholangiopancreatography. Recently, endosonography-guided biliary drainage (ESBD) has been developed as a new biliary drainage technique. Current issues regarding ESBD are discussed in this article. Proper indications for ESBD should be established for widespread performance. Technical standardization and dedicated instruments for ESBD are also mandatory.

Gallbladder cancer occurs frequently in patients with pancreaticobiliary maljunction due to pancreatobiliary reflux. Pancreatobiliary reflux is also detected in some patients with a relatively long common channel. This study aimed to clarify the correlation between pancreatobiliary reflux and the length of a common channel.Two hundred and three patients, in whom both the length of a common channel and amylase level in the bile were measured, were enrolled from nine centers.Bile amylase level was correlated with the length of a common channel (P0.01). The minimum length of a common channel that could induce a markedly elevated amylase level in the bile (1,000 mg/dl) was determined as 5 mm. We redefined high confluence of pancreatobiliary ducts (HCPBD) as cases with a common channelor = 5 mm, in which the communication between the pancreatic and bile ducts was occluded with the sphincter contraction. Gallbladder cancer was found in 20% of 56 redefined HCPBD patients. Bile amylase level1,000 mg/dl and biliopancreatic reflux were detected in 79 and 95% of the patients, respectively.Patients with a common channelor = 5 mm (redefined HCPBD) should be monitored for the development of gallbladder cancer, as they frequently showed significant pancreatobiliary reflux.

The diagnostic efficacy of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) cytology may vary greatly depending on the treatment of the samples obtained and the level of proficiency of the cytopathologist or cytoscreener. We prospectively evaluated the diagnostic efficacy of the cell block (CB) method and that of smear cytology using tissue samples obtained in the same needle pass at EUS-FNA in 33 patients with pancreatic tumors, abdominal tumors or swollen lymph nodes. An average of 3.1 passes were applied during the procedure without affirmation by rapid cytology. About half of the material obtained by each single pass was subjected to smear cytology, while the other half was evaluated by the CB method. Four to 12 glass slides were prepared for both Papanicolaou stain and Giemsa stain. The CB sections were prepared using the sodium alginate method and subjected to HE, PAS-AB and immunohistochemical stains. Two pathologists independently made cytological and histological diagnoses. The final diagnosis was based on integration of cytohistological findings, diagnostic imaging, and clinical course. The diagnostic accuracy of the CB method and that of smear cytology were 93.9 and 60.6%, respectively (p = 0.003), and their respective sensitivities were 92.0 and 60.0% (p = 0.02). It was easier to make a definite diagnosis of not only malignancies but also benign conditions by the CB method than by the smear method. The CB method with immunostaining showed a higher diagnostic yield than smear cytology in patients who had undergone EUS-FNA without rapid on-site cytology.

Endoscopic papillectomy has been reported to be the treatment of choice in patients with ampullary adenoma. For ampullary cancer, pancreaticoduodenectomy is the standard treatment. Since neither lymphatic permeation, vascular invasion, nor lymph node metastasis is observed in patients with ampullary cancer limited to the mucosa, endoscopic resection of such tumors can be justified if no ductal infiltration into the bile or pancreatic duct is documented. For its application, accurate preoperative staging is mandatory. Transpapillary intraductal ultrasonography can provide useful information for making therapeutic decisions, especially in the selection of patients for endoscopic papillectomy.

Aim: For patients with bowel obstruction, intestinal decompression by a long tube is recommended. We assessed the usefulness of a new technique for insertion of a long tube with a guidewire placed by transnasal ultrathin endoscopy. Methods: Nineteen patients who had been diagnosed as suffering from bowel obstruction underwent long-tube insertion with the ropeway technique using a guidewire placed by transnasal endoscopy. Thirty-three patients who had undergone conventional insertion of a long tube were included as controls. The success rate of intubation of the small bowel and the time required for the procedure were compared between the subjects and controls. Results: The success rate of intubation was 94.7% (18/19) in subjects and 84.8% (28/33) in controls (P = 0.53). The time required for insertion in the subjects and controls was 24.1 ± 8.1 min and 48.7 ± 25.3 min, respectively, with a statistically significant difference (P

Background It is often difficult to insert a long intestinal tube in the small bowel of patients with bowel obstruction, and it often results in long procedure time and severe patient distress. Objective To assess the usefulness of the ropeway method by using a guidewire placed with the assistance of transnasal ultrathin endoscopy in long-tube insertion for patients with bowel obstruction. Design Prospective, randomized, controlled, single-center study. Patients and Interventions Thirty-four consecutive patients with bowel obstruction requiring decompression participated in the study and were randomized to the insertion of a long tube with the ropeway method (ILTR) group (ie, insertion along an endoscopically placed guidewire that was passed through only the distal 4 cm of the tube) or insertion by a conventional method group (C group). Main Outcome Measurements The time required for the procedure (main), success rate, x-ray exposure time, and intensity of patient distress measured with a visual analog scale of 1 to 5 (better to worse). Results The mean (± standard deviation) duration of the procedure in the successful cases in the ILTR group and the C group was 16.1 ± 5.6 minutes and 26.4 ± 13.8 minutes, respectively ( P = .010). The success rate was 100% in the ILTR group and 88% in the C group ( P = .48). The mean (± standard deviation) x-ray exposure time and intensity of patient distress were, respectively, 16.4 ± 8.7 minutes and 33.2 ± 12.3 minutes ( P P = .016). Limitations Single-center study and small sample size to evaluate overall safety. Conclusions Long-tube insertion for bowel obstruction with the ropeway method facilitated by transnasal ultrathin endoscopy was superior to conventional fluoroscopic placement with regard to overall procedure success, time required, and patient comfort.

Prior Billroth II gastrectomy is an important factor presenting difficulties in endoscopic retrograde cholangiopancreatography (ERCP) administration. We retrospectively evaluated the usefulness and safety of therapeutic ERCP using an anterior oblique-viewing endoscope for bile duct stones in patients with prior Billroth II gastrectomy.Forty-three patients with bile duct stones after Billroth II gastrectomy who underwent ERCP from January 1998 to February 2008 were enrolled in this study. We used anterior oblique-viewing endoscopes for all procedures. Endoscopic sphincterotomy was performed using a needle knife guided by a biliary stent. A total of 808 patients without gastrectomy who had undergone ERCP for bile duct stones in the same period were reviewed as controls.The success rate of access to the papilla of Vater was 88.4%, and the average time required for such access was 13 min. In cases of successful access, selective cannulation of the bile duct and complete stone removal were achieved in 94.7% and 94.6% of patients, respectively. The incidence of complications was 4.7%. As for the success rate of selective cannulation, complete stone removal ratio, and the incidence of complications, there were no significant differences compared with the control group.Use of an anterior oblique-viewing endoscope enables good success rates in selective cannulation and complete stone removal to be achieved in patients with prior Billroth II gastrectomy. The safety of therapeutic ERCP for removal of bile duct stones in those patients is comparable to that in patients with normal anatomy.

We present a case of small pancreatic head cancer with pancreas divisum preoperatively diagnosed by pancreatic juice cytology. A 60-year-old woman was referred to our hospital for evaluation of a dilated main pancreatic duct (MPD). A small and poorly reproducible low-echoic lesion in the pancreas was suspected by ultrasonography (US) and endoscopic ultrasonography (EUS). Magnetic resonance cholangiopancreatography (MRCP) failed to visualize the ventral pancreatic duct, and the upstream dorsal pancreatic duct was dilated. Endoscopic retrograde cholangiopancreatography (ERCP) was indicative of pancreas divisum, and complete obstruction of the MPD in the pancreatic head was seen. Cytology of pancreatic juice obtained from the dorsal pancreas after minor papilla sphincterotomy revealed the presence of adenocarcinoma cells. Pancreatoduodenectomy was performed under the diagnosis of pancreatic head cancer with pancreas divisum. Histological examination revealed moderately-differentiated tubular adenocarcinoma 20 mm in diameter, located in the pancreatic head. Dilatation of the dorsal pancreatic duct is sometimes observed in cases with pancreas divisum without the presence of tumors. When pancreatic duct stenosis also exists in such cases, even if a tumor is not clearly visualized by diagnostic imaging, vigorous examinations such as pancreatic juice cytology are recommended to establish an accurate diagnosis.

Endosonography-guided biliary drainage (ESBD) is a new option that allows establishment of biliary drainage. Due to the diameter of the working channel of an echoendoscope, it is necessary to replace a small caliber stent with a larger one to lessen the risk of stent occlusion. However, insertion of a guidewire into the bile duct via the hole of the sinus tract following direct removal of a previously placed stent is not always possible, resulting in guidewire passage outside the fistula and bile leakage. Cannulation of the previously deployed stent, guidewire insertion into the bile duct via the cannula and the stent, and removal of the stent with the snare over the guidewire leaving the guidewire in place (the snare-over-the-wire technique [SOW]) for stent exchange following ESBD was attempted. Four patients who required stent exchange following ESBD were included in the present study to evaluate the feasibility and usefulness of SOW. SOW was successful in all the cases. A new stent was also successfully deployed over the guidewire in all the cases. No complications were encountered. The snare-over-the-wire technique is feasible and useful in stent exchange following ESBD for the reduction of the risk of guidewire migration.

Endosonography-guided biliary drainage (ESBD) is gaining acceptance as an effective treatment for obstructive jaundice. Only a few reports on the application of this technique to the gallbladder (endosonography-guided gallbladder drainage [ESGBD]) have been published in the literature. In order to relieve acute cholecystitis which developed in a patient with unresectable malignant biliary obstruction after deployment of a covered metal stent (CMS), we applied this technique. ESGBD was carried out by using an electronic curved linear array echoendoscope. After visualization of the gallbladder and determination of the puncture route, a needle knife papillotome was advanced with electrocautery to pierce the gastric and gallbladder walls. Under the guidance of a guidewire inserted through the needle sheath into the gallbladder, a 7.2 Fr, 30 cm-long, single pigtail plastic tube was placed to bridge the gallbladder and the stomach. No complications relevant to the procedure were encountered. ESGBD was quite effective in ameliorating the patient's acute cholecystitis and the drainage tube was removed after 10 days without sequelae. Acute cholecystitis following CMS deployment is considered to be a good indication for ESGBD.

In 2006, the Japan Pancreas Society revised the diagnostic criteria for autoimmune pancreatitis (AIP) so as to more clearly define its morphological, pathological, and immunological features, as follows: (1) diffuse or segmental narrowing of the main pancreatic duct with an irregular wall and diffuse or localized enlargement of the pancreas recognized by imaging studies; (2) high serum gamma globulin, IgG, or IgG4 levels, or the presence of autoantibodies; and (3) marked interlobular fibrosis and prominent infiltration of lymphocytes and plasma cells in the periductal area, occasionally with lymphoid follicles in the pancreas. Establishing a diagnosis of AIP has become easier with knowledge of its immunological abnormalities, including serum IgG4 levels. However, the localized form of AIP sometimes mimics pancreatic cancer. The rate of focal mass formation in patients with AIP is reportedly 24%-43%; however, there have been few reports on the histological findings of localized AIP, in contrast to mass-forming pancreatitis (MFP). Our review of patients who had undergone resection due to a preoperative diagnosis of MFP with possible cancer revealed 72% to be patients with localized AIP. For the discrimination of these conditions, it is important to recognize the characteristic ultrasonographic findings of AIP, i.e., (1) diffuse or localized enlargement and hypoechogenicity of the pancreas; (2) rarity of calcification, cystic lesions, and peripancreatic fluid collection; (3) thickened layer structure of the bile duct wall; (4) iso/hypervascularity in the swollen portion of the pancreas; (5) attenuation of pancreatic swelling and bile duct wall thickening after steroid therapy; and (6) multiple hypoechoic masses in various organs, including the pancreas. Contrast-enhanced endoscopic ultrasonography is potentially a useful tool in the differential diagnosis and for assessment of the efficacy of steroid therapy by enabling evaluation of the vascularity of the lesions. Along with the presence of IgG4-positive plasma cells, verification of obliterative phlebitis is highly specific for the histological diagnosis of AIP.

Aim: We evaluated the diagnostic efficacy of transpapillary intraductal ultrasonography before biliary drainage (IDUS-BD) and transpapillary biopsy (TPB) for the assessment of the longitudinal extent of bile duct cancer. Methods: Between November 1999 and January 2005, we performed IDUS-BD and TPB preoperatively in 27 patients with carcinoma of the extrahepatic bile duct. Following IDUS-BD, TPB was performed under fluoroscopic guidance immediately after endoscopic sphincterotomy. The diagnostic efficacy of IDUS-BD and TPB for the longitudinal extent of the cancer and the complications which accompanied the procedure were evaluated. Results: The overall success rate of sampling and the diagnostic accuracy of bile duct cancer by TPB were 85.3% (192/225) and 85% (23/27), respectively. The sensitivity, specificity and accuracy of the assessment of the longitudinal extent of cancer on the hepatic and duodenal sides by IDUS-BD were 82%, 70%, 78% and 85%, 43%, 70%, respectively. Those by a combination of IDUS-BD and TPB were 88%, 80%, 85% and 77%, 86%, 80%, respectively. Overestimation of the longitudinal extent of BD cancer by IDUS-BD was mainly due to inflammation and obscure images, especially resulting from collapse of the bile duct on the duodenal side of the tumor, and was corrected by TPB in four of five patients. No serious complications occurred following the combination of IDUS-BD and TPB. Conclusions: TPB is useful for preoperative histological diagnosis of bile duct cancer. The combination of IDUS-BD and TPB is practical for evaluation of its longitudinal extent; basically, IDUS-BD is sufficient on the hepatic side of the tumor, but concomitant TPB is recommended on the duodenal side.

Endoscopic biliary drainage (e.g. endoscopic biliary stenting [EBS]) is the treatment of choice in the management of obstructive jaundice due not only because of its lesser invasiveness and greater safety as compared with surgical drainage or percutaneous transhepatic biliary drainage (PTBD), but also due to its ability to maintain the physiological flow of bile. EBS, however, is not always possible, and surgical drainage or PTBD have been performed in such cases with difficult cannulation of the bile duct or difficult intubation of the duodenum with a duodenoscope during endoscopic retrograde cholangiopancreatography (ERCP).Recently,the role of endoscopic ultrasonography (EUS),or endosonography (ES),has expanded from simply obtaining cross-sectional images of the gut wall or surrounding organs and tissue samples by fine-needle aspiration cytology/biopsy to therapeutic applications. Endosonography-guided biliary drainage (ESBD) is one of such therapeutic applications of ES and reports on this procedure are increasing. In the present article, technical aspects and the current status of ESBD are discussed.As in EBS,ESBD makes it possible to recover physiological bile flow without pain following the procedure.Therefore,ESBD is expected to soon be widely accepted as a new option for difficult cases of not only EBS but also PTBD with obstructive jaundice, and may become the treatment of choice in selected cases. Development of relevant devices will expand its indications and accelerate its spread.

Cystic duct cancer fulfilling Farrar's criteria is relatively rare, but tumors whose origin is estimated to be in the cystic duct exist. The clinical features of such "broadly defined" cystic duct cancer have not been clarified.The endoscopic retrograde cholangiography (ERC) findings, intraductal ultrasonography (IDUS) findings, histological findings, and prognoses of 11 cases of cystic duct cancers resected at our institution (group C) were retrospectively analyzed. As a control group, 55 cases of middle or lower bile duct cancer (group B) were used (in 20 of the 55 cases of group B, tumors extended to the cystic duct intraluminally (group B-C (+)).(1) ERC findings of group C as compared with those of group B-C (+) were as follows: (a) unilateral bile duct narrowing (spoon-like appearance): 55% versus 5% (P0.01); (b) bilateral bile duct narrowing (apple-core-like appearance): 27% versus 95% (P0.001). (2) IDUS was unable to visualize the cysticocholedochal junction (negative "confluence sign") more often in group C (67%) than in group B-C (+) (13%) (P0.01). (3) Histologically, tumors extended to the gallbladder and the bile duct in 36% and 91% of the cases in group C, respectively. (4) The median survival time of the two groups was 21 and 28 months, respectively.Cystic duct cancers frequently extended to the bile duct. The spoon-like appearance by ERC and the negative confluence sign by IDUS were characteristic findings.

An 18-year-old healthy woman was admitted to our department for further evaluation of a pancreatic mass (45 mm in diameter) by transabdominal ultrasound at a general health check. Solid-pseudopapillary tumor (SPT) was suspected from the findings of diagnostic images. Therefore, surgery was recommended. The patient and her family, however, refused surgery. Ultrasound-guided transcutaneous biopsy revealed proliferation of tumor cells with small nuclei showing a pseudopapillary arrangement. PAS positive granules and alpha-1-antitrypsin positive cells were proven, which led to the diagnosis of SPT. As the grade of atypism of the tumor cells was low, the patient underwent follow-up examination once a year at our outpatient department thereafter. The tumor gradually decreased its maximum diameter in 10 years from 45 mm to 15 mm. Thus far, there have been very few reports on the natural course of SPT, and this is the first report describing marked spontaneous shrinkage of a tumor in a long follow-up period.

症例は53歳女性．慢性膵炎の急性増悪と膵仮性嚢胞内の出血，増大にて入院となり，内視鏡的ドレナージ術を施行した．膵頭部の60mm大の仮性嚢胞に対し胃前庭部から超音波内視鏡（EUS）下に穿刺し，0.035inchのガイドワイヤーを挿入後，5Frのテーパードカテーテルから段階的な穿刺ルートの拡張を試みた．しかし，嚢胞壁は慢性炎症性変化で12mmと著明に肥厚，硬化しており，拡張が困難であった．そこでガイドワイヤーチャンネル付きのニードルナイフを用いて胃壁および嚢胞壁を通電切開したところ，嚢胞内へのアプローチが可能となった．これによりカテーテル径5Frの拡張用バルーンカテーテルが嚢胞内へ挿入可能となり，嚢胞壁を拡張して6.5Fr経鼻外瘻チューブを留置しえた． 今回われわれは12mmの厚い嚢胞壁を有する膵仮性嚢胞に対しEUSガイド下ドレナージを施行したところ，穿刺後，肥厚，硬化した嚢胞壁のため瘻孔拡張に難渋したが，ガイドワイヤー式ニードルナイフおよび細径拡張用バルーンカテーテルの併用が有用であった．

To elucidate the correlation of autoimmune pancreatitis (AIP) and mass-forming pancreatitis, in which a localized mass is formed in the pancreas.Nine cases of mass-forming pancreatitis were divided into two groups, one consisting of cases that met the histological diagnostic criteria for AIP by the Japan Pancreas Society (JPS) and the other consisting of cases which did not. Histological findings, immunohistological findings, and pancreatograms were compared between these groups.Six cases met the histological criteria of JPS (group A) and the other three did not (group B). In the mass-forming portion in group A, the wall of the pancreatic duct showed marked thickening. However, the epithelium was well preserved, and dilatation of the branch ducts or protein plugs were rarely observed. All cases showed marked obliterative phlebitis. The IgG4 labeling index (LI) was 25% or more in all but one case. In the portion other than the mass, the lobular structure was well preserved and the IgG4 LI was less than 10%. The pancreatogram showed localized stenosis or obstruction at the site of the mass associated with a normal-appearing main pancreatic duct in the remaining portion. In group B, histological findings typical of chronic pancreatitis with dilated branch ducts and protein plugs were observed. Obliterative phlebitis was not confirmed. The IgG4 LI in the mass-forming portion was low (2.3%-11.1%).There exists a subgroup of AIP showing localized mass formation and stenosis or obstruction of the main pancreatic duct with prominent obliterative phlebitis associated with a normal ductal segment.

Endoscopic retrograde cholangiopancreatography (ERCP) is accepted as a safe, direct technique for evaluating pancreatobiliary diseases. Since the introduction of endoscopic sphincterotomy (EST), ERCP has evolved from a diagnostic procedure to a therapeutic one. ERCP with EST and stone removal is a valuable therapeutic modality in choledocholithiasis. Herein are reviewed the complications of EST in cases of choledocholithiasis along with a discussion of the risk management of this particular procedure. Pancreatitis is the most common ERCP-related complication. Hemorrhage is primarily a complication related to sphincterotomy. Other complications include perforation, cholangitis, cholecystitis, and sedation-related cardiopulmonary complications. Endoscopists who perform ERCP should have appropriate training and be knowledgeable of such complications.

A 74-year-old woman, who had suffered from acute cholangitis, was referred to our department for further evaluation of the biliary tree. A diagnosis of choledochocele was made by endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography. A small flat elevation with cholesterolosis was observed in the lower bile duct, and circumferential wall thickening was apparent in some parts of the upper and middle bile duct by intraductal ultrasonography and peroral cholangioscopy. With the diagnosis of choledochocele associated with superficial spreading cancer and cholesterolosis of the bile duct, pylorus-preserving pancreaticoduodenectomy was carried out. Microscopically, the tumor had spread extensively from the lower to the upper bile duct. Its invasion was limited to the mucosa for the most part, with microinvasion of the subserosa in the upper bile duct. In the lower bile duct, foamy cells were located beneath the neoplastic epithelium of the elevation. The number of cases of choledochocele associated with biliary cancer is becoming higher than previously reported. This anomaly may play some role in the development of biliary malignancy. Histological examination seems to be mandatory before making a diagnosis of cholesterolosis of the bile duct, since this condition may occasionally accompany cancer.